Basic Information
| Provider Information | |||||||||
| NPI: | 1437793601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAFULOVIC | ||||||||
| FirstName: | KIERSTIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | OT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | LEAK | ||||||||
| OtherFirstName: | KIERSTIN | ||||||||
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| OtherCredential: | OT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 33900 HARPER AVE STE 104 | ||||||||
| Address2: | |||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480354258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5863502644 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 30100 TELEGRAPH RD STE 140 | ||||||||
| Address2: | |||||||||
| City: | BINGHAM FARMS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480254516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483850030 | ||||||||
| FaxNumber: | 2488499980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2019 | ||||||||
| LastUpdateDate: | 10/21/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 5201009369 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.